High prevalence of unhealthy alcohol use and comparison of self-reported alcohol consumption to phosphatidylethanol among women engaged in sex work and their male clients in Cambodia

BACKGROUND:

In Cambodia, most of the female sex workers (FSW) work in venues where unhealthy alcohol use is ubiquitous and potentially contributing to the HIV epidemic. However, no accurate data exists. We compare self-reported unhealthy alcohol consumption to a biomarker of alcohol intake in Cambodian FSW and male clients, and determine factors associated with unhealthy alcohol use.

METHODS:

A cross-sectional study was conducted among FSW (n=100) and male clients (n=100) in entertainment and sex work venues in Cambodia. Self-reported unhealthy alcohol use (AUDIT-C) was compared to phosphatidylethanol (PEth) positive (≥50ng/ml), a biomarker of alcohol intake. Sociodemographics data was collected. Correlates of self-reported unhealthy alcohol use and PEth positive were determined.

RESULTS:

The prevalence of PEth positive in FSW was 60.0%. Self-reported unhealthy alcohol consumption was reported by 85.0% of the women. Almost all women (95.0%) testing PEth positive also reported unhealthy alcohol use. Prevalence of unhealthy alcohol consumption (self-report and PEth positive) was higher in FSW working in entertainment establishments compared to other sex work venues (p<0.01). Among male clients, 47.0% reported unhealthy alcohol consumption and 42.0% had a PEth positive. However, only 57.1% of male clients with PEth positive reported unhealthy alcohol use.

CONCLUSIONS:

Unhealthy alcohol consumption is prevalent in Cambodian sex work settings. Self-reported unhealthy alcohol use is well reported by FSW, but less by male clients. These findings highlight the urgency of using accurate measures of unhealthy alcohol consumption and integrating this health issue into HIV prevention interventions.

Purchase full article at:  http://goo.gl/OVW2hK

By:  Couture MC¹, Page K², Sansothy N³, Stein E⁴, Vun MC⁵, Hahn JA⁶.

¹Department of Population Health Sciences, School of Nursing and Health Professions, University of San Francisco, 2130 Fulton St., San Francisco, CA 94117, United States. Electronic address: mcouture@usfca.edu.

²University of New Mexico Health Sciences Center, Dept. of Internal Medicine MSC 10 5550, 1 University of New Mexico, Albuquerque, NM 87131, United States.

³National Center for HIV, AIDS, Dermatology and STDs, #245H, Street 6A, Phum Kean Khlang, Sangkat Prekleap Russey Keo, Phnom Penh, Cambodia; University of Health Sciences-Cambodia, #73 Monivong Boulevard, Srah Chak, Phnom Penh, Cambodia.

⁴Global Health Sciences/Prevention and Public Health Group, University of California San Francisco, Mission Hall, 550 16th St., Third Fl., Box 1224, San Francisco, CA 94158, United States.

⁵National Center for HIV, AIDS, Dermatology and STDs, #245H, Street 6A, Phum Kean Khlang, Sangkat Prekleap Russey Keo, Phnom Penh, Cambodia.

⁶Department of Medicine, University of California San Francisco, Mission Hall, 550 16th St., Third Fl., Box 1224, San Francisco, CA 94158, United States.

Drug Alcohol Depend. 2016 May 21. pii: S0376-8716(16)30117-X. doi: 10.1016/j.drugalcdep.2016.05.011. [Epub ahead of print]

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HIV Prevalence and Risks Associated with HIV Infection among Transgender Individuals in Cambodia

INTRODUCTION:

Recognizing transgender individuals have a high risk of HIV acquisition, and to inform policies and programming, we conducted an HIV prevalence and risk behaviors survey among transgender individuals in Cambodia.

METHODS:

Cross-sectional survey using a respondent driven sampling method with self-administered audio-computer assisted interviews. HIV testing was performed prior to the questionnaire with results available immediately after. Eligible participants were ≥18 years, identified as male at birth and self-identified/expressed as a different gender, and reported having sex with at least one male partner in past year. From six major urban centers of Cambodia, 891 transgender individuals were recruited.

RESULTS:

The majority of the 891 participants self-identified as third gender or female (94.5%), were young (median age 23, IQR [20-27]), had secondary education or higher (80.5%), not married (89.7%), and employed (90.2%). The majority had first sex before 18 years (66.8%), with a male (79.9%), 37.9% having been paid or paying for this first sex. The rate of HIV positivity among participants was found to be 4.15%. Consistent condom use with male and female partners was low with all partner types, but particularly low with male partners when paying for sex (20.3%). The majority of participants reported having experienced discrimination in their lifetime (54.8%) and 30.3% had been assaulted. Multivariate analysis revealed that older age (adjusted OR = 14.73 [4.20, 51.67] for age 35-44 and adjusted OR = 7.63 [2.55, 22.81] for age 30-34), only having a primary school education or no schooling at all (adjusted OR = 2.62 [1.18, 5.80], being a resident of Siem Reap (adjusted OR = 7.44 [2.37,23.29], receiving payment at first sex (adjusted OR = 2.26 [1.00, 5.11], having sex during/after using drugs (adjusted OR = 2.90 [1.09,7.73]), inconsistent condom use during last anal sex (adjusted OR = 3.84 [1.58, 9.33]), and reporting low self-esteem (adjusted OR = 3.25 [1.35,7.85]) were independently associated with HIV infection.

Below:  A. Condom use with partners during past 6 months by sex transaction type, with female partners. B. Condom use with partners during past 6 months by sex transaction type, with male partners.

CONCLUSIONS:

This study confirms transgender individuals as one of the highest-risk groups for HIV infection in Cambodia. It suggests the need for programmatic strategies that mitigate identified associated risks and facilitate access to HIV care for this population.

Full article at:   http://goo.gl/MDR3Ih

By:  Weissman A1, Ngak S1, Srean C1, Sansothy N2, Mills S3, Ferradini L1.

• 1FHI 360, Phnom Penh, Cambodia.
• 2National Center for HIV/AIDS, Dermatology and Sexually Transmitted Diseases, (NCHADS) and University of Health Science, Phnom Penh, Cambodia.
• 3FHI 360, Bangkok, Thailand. 

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The impact of violence on sex risk and drug use behaviors among women engaged in sex work in Phnom Penh, Cambodia

HIGHLIGHTS

• Almost half the women engaged in sex work reported violence in the past 12 months.
• Prior physical violence exposure associated with subsequent sexual risk taking.
• Physical violence was associated with amphetamine type stimulant (ATS) use.
• Sexual violence was associated lower levels of condom use with non-paying partners.

BACKGROUND:

Violence, substance use, and HIV disproportionately impact female entertainment and sex workers (FESW), but causal pathways remain unclear.

METHODS:

We examined data from an observational cohort of FESW age 15-29 in Phnom Penh, Cambodia for associations between violence exposure and sexual risk and drug use. Validated measures of physical and sexual violence were assessed at baseline. Self-reported outcomes measured quarterly over the next 12-months included past month sexual partners, consistent condom use by partner type, sex while high, and amphetamine type stimulant (ATS) use. Biomarkers measured quarterly included prostate specific antigen (PSA) and urine toxicology. Generalized estimating equations were fit adjusting for age, education, marital status and sex work venue.

RESULTS:

Of 220 women, 48% reported physical or sexual violence in the preceding 12-months. Physical violence was associated with increased number of sex partners (adjusted incidence rate ratio [aIRR] 1.33; 95% CI: 1.04-1.71), greater odds of sex while high (adjusted odds ratio [aOR] 2.42; 95% CI: 1.10-5.33), increased days of ATS use (aIRR 2.74; 95% CI: 1.29-5.84) and increased odds of an ATS+ urine screen (aOR 2.80, 95%CI: 1.38-5.66). Sexual violence predicted decreased odds of consistent condom use with non-paying partners (aOR 0.24; 95% CI: 0.10-0.59) and greater odds of a PSA+ vaginal swab (aOR 1.83; 95% CI: 1.13-2.93).

CONCLUSIONS:

Physical and sexual violence are prevalent among Cambodian FESW and associated with subsequent sexual risk and drug use behaviors. Clinical research examining interventions targeting structural and interpersonal factors impacting violence is needed to optimize HIV/AIDS prevention among FESW.

Purchase full article at:  http://goo.gl/uqKW9I

By:  Draughon Moret JE1, Carrico AW2, Evans JL3, Stein ES4, Couture MC5, Maher L6, Page K7; Young Women’s Health Study Collaborative.

• 1The Betty Irene Moore School of Nursing at UC Davis, 4610 X Street, #4202 Sacramento, CA 95817, United States. Electronic address: jdmoret@ucdavis.edu.
• 2University of California San Francisco, School of Nursing, 2 Koret Way, San Francisco, CA 94143, United States. Electronic address: adam.carrico@ucsf.edu.
• 3UCSF Global Health Sciences/Prevention and Public Health Group, Mission Hall, 550 16th St., Third Fl., Box 1224, San Francisco, CA 94158, United States. Electronic address: jennifer.evans@ucsf.edu.
• 4UCSF Global Health Sciences/Prevention and Public Health Group, Mission Hall, 550 16th St., Third Fl., Box 1224, San Francisco, CA 94158, United States. Electronic address: ellen.stein@ucsf.edu.
• 5University of San Francisco, School of Nursing and Health Professions, Department of Population Sciences, 2130 Fulton St., San Francisco, CA 94117, United States. Electronic address: mcouture@usfca.edu.
• 6The Kirby Institute for Infection and Immunity, UNSW Australia, Sydney, NSW 2052, Australia. Electronic address: lmaher@kirby.unsw.edu.au.
• 7Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Department of Internal Medicine, MSC 10 5550, 1 University of New Mexico, Albuquerque, NM 87131, United States. Electronic address: pagek@salud.unm.edu.
• Drug Alcohol Depend. 2016 Apr 1;161:171-7. doi: 10.1016/j.drugalcdep.2016.01.028. Epub 2016 Feb 6. 

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Mental Health among Men Who Have Sex with Men in Cambodia: Implications for Integration of Mental Health Services within HIV Programs

BACKGROUND:

Poor mental health contributes to poor HIV prevention, treatment and care outcomes. This paper documents factors associated with psychological distress among men who have sex with men (MSM) in Cambodia and discusses potential ways in which routine mental health management could be integrated into HIV services.

METHODS:

A cross-sectional study was conducted in 2014 among 394 MSM randomly selected from two provinces using a two-stage cluster sampling method. A structured questionnaire was used to assess psychological distress, sexual behaviors, substance use, adverse childhood experiences and family dysfunction. Multivariate logistic regression analysis was performed to explore factors associated with levels of psychological distress.

RESULTS:

In total, 10.7 % of the respondents reported having suicidal thoughts and 6.6 % reported having attempted to commit suicide in the past three months, while 38.8 % had a higher level of psychological distress, which indicates poor mental health. Higher levels of psychological distress were independently associated with older age, alcohol use, illicit drug use, poor self-reported quality of life, and reduced condom use at last sex. MSM with higher levels of psychological distress were significantly more likely to report that a family member said hurtful things to them, a parent or guardian had been physically abused, and a family member had been mentally ill when they were growing up.

CONCLUSIONS:

In order to mitigate psychological distress among MSM in Cambodia, integration of mental health interventions within HIV programmes should be strengthened. To achieve optimal impact, these interventions should also address alcohol and other substance use, and low condom use among distressed MSM. In addition, training of clinical and non-clinical HIV service providers to screen for mental health symptoms, and subsequent provision of peer-based outreach and social support for MSM identified with psychological distress is required.

Comparisons of sexual behaviors and HIV/STI testing among MSM with a lower and higher level of psychological distress

Sexual behaviors in the past 3 months	Total	Total GHQ-12 score
	(n = 394)	≤3 (n = 241)	>3 (n = 153)	p-value*
Mean number of sex partners	3.9 ± 5.4	3.8 ± 5.7	4.0 ± 5.0	0.68
Used a condom in the last sex	313 (82.8)	202 (87.4)	211 (75.5)	0.003
Had sex with girlfriends	118 (29.9)	79 (32.7)	39 (15.4)	0.03
Mean number of girlfriends you had sex with	1.7 ± 1.1	1.7 ± 1.0	1.9 ± 1.2	0.26
Used a condom in last sex with girlfriends	97 (82.2)	68 (86.1)	29 (74.4)	0.12
Had sex with boyfriends	206 (86.9)	126 (85.7)	80 (88.9)	0.48
Mean number of boyfriends you had sex with	2.4 ± 3.8	2.3 ± 3.5	2.6 ± 4.3	0.53
Used a condom in last sex with boyfriends	192 (92.8)	117 (92.9)	75 (92.6)	0.94
Had anal sex with boyfriends	196 (94.2)	116 (91.3)	80 (98.8)	0.03
Used condom in last anal sex with boyfriend	187 (92.1)	114 (94.2)	73 (89.0)	0.18
Sold sex to men	67 (17.0)	42 (17.4)	25 916.3)	0.78
Used condom when selling sex last time	63 (94.0)	40 (95.2)	23 (92.0)	0.59
Tested for HIV in the past 6 months	252 (64.0)	160 (66.4)	92 (60.1)	0.21
Been diagnosed with an STI	28 (7.1)	16 (6.6)	12 (7.9)	0.63

GHQ general health questionnaire, MSM men who have sex with men, STI sexually transmitted infection

Values are number (%) for categorical variables and mean ± SD for continuous variables

*Chi-square test or Fisher’s exact test was used as appropriate for categorical variables and Student’s t-test was used for continuous variables

Full article at:   http://goo.gl/nJqgnZ

By:  Yi S1, Tuot S1, Chhoun P2, Pal K2, Choub SC2, Mburu G3,4.

• 1Research Department, KHANA, Phnom Penh, Cambodia.
• 2Programs Department, KHANA, Phnom Penh, Cambodia.
• 3Program Impact Unit, International HIV/AIDS Alliance, Brighton, UK. gmburu@aidsalliance.org.
• 4Department of Health Research, Lancaster University, Lancaster, UK. gmburu@aidsalliance.org. 

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Increased Case Notification through Active Case Finding of Tuberculosis among Household and Neighbourhood Contacts in Cambodia

Background

Globally, there has been growing evidence that suggests the effectiveness of active case finding (ACF) for tuberculosis (TB) in high-risk populations. However, the evidence is still insufficient as to whether ACF increases case notification beyond what is reported in the routine passive case finding (PCF). In Cambodia, National TB Control Programme has conducted nationwide ACF with Xpert MTB/RIF that retrospectively targeted household and neighbourhood contacts alongside routine PCF. This study aims to investigate the impact of ACF on case notifications during and after the intervention period.

Methods

Using a quasi-experimental cluster randomized design with intervention and control arms, we compared TB case notification during the one-year intervention period with historical baseline cases and trend-adjusted expected cases, and estimated additional cases notified during the intervention period (separately for Year 1 and Year 2 implementation). The proportion of change in case notification was compared between intervention and control districts for Year 1. The quarterly case notification data from all intervention districts were consolidated, aligning different implementation quarters, and separately analysed to explore the additionality. The effect of the intervention on the subsequent case notification during the post-intervention period was also assessed.

Results

In Year 1, as compared to expected cases, 1467 cases of all forms (18.5%) and 330 bacteriologically-confirmed cases (9.6%) were additionally notified in intervention districts, whereas case notification in control districts decreased by 2.4% and 2.3%, respectively. In Year 2, 2737 cases of all forms (44.3%) and 793 bacteriologically-confirmed cases (38%) were additionally notified as compared to expected cases. The proportions of increase in case notifications from baseline cases and expected cases to intervention period cases were consistently higher in intervention group than in control group. The consolidated quarterly data showed sharp rises in all forms and bacteriologically-confirmed cases notified during the intervention quarter, with 64.6% and 68.4% increases (compared to baseline cases), and 46% and 52.9% increases (compared to expected cases), respectively. A cumulative reduction of case notification for five quarters after ACF reached more than -200% of additional cases.

Conclusions

The Cambodia’s ACF with Xpert MTB/RIF that retrospectively targeted household and neighbourhood contacts resulted in the substantial increase in case notification during the intervention period and reduced subsequent case notification during the post-intervention period. The applicability of retrospective contact investigation in other high-burden settings should be explored.

Below:  Annualized TB case notification rate by quarter

Below:  Proportion of bacteriologically-confirmed cases among total notified cases, adjusted by implementation timing

Full article at:   http://goo.gl/1vn9L0

By:  

Fukushi Morishita, Nobuyuki Nishikiori 
World Health Organization Regional Office for the Western Pacific, Manila, Philippines

Mao Tan Eang 

National Center for Tuberculosis and Leprosy Control, Ministry of Health, Phnom Penh, Cambodia

Rajendra-Prasad Yadav 

World Health Organization Representative Office in Cambodia, Phnom Penh, Cambodia

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Cluster of HIV Infections Attributed to Unsafe Injection Practices — Cambodia, December 1, 2014–February 28, 2015

Summary

What is already known about this topic?

Unsafe medical injection practices have been reported in Cambodia during the last decade. Current national human immunodeficiency virus (HIV) prevalence estimates do not include HIV transmission risk associated with unsafe injection or blood transfusion. HIV testing and surveillance in Cambodia are focused on high risk groups, including men who have sex with men, persons who inject drugs, and commercial sex workers.

What is added by this report?

The largest cluster of new HIV infections ever attributed to unsafe injections among a general population was reported in a rural area of Cambodia; 2.7% of residents were infected. The outbreak was detected after increased demand for HIV testing by residents who perceived themselves to be at risk after exposure to an unlicensed provider of injections and intravenous infusions.

What are the implications for public health practice?

HIV prevention strategies that target specific populations often do not consider the risk for HIV transmission via unsafe injections in the general population. Further studies are needed to clarify HIV prevalence in general populations where HIV risk perception is low; quantify the risk for other bloodborne infections (e.g., hepatitis C) via unsafe injections; understand public demand for medical injections; and improve health care workers’ injection practices in the public and private sectors. Measures to reduce both the demand for unnecessary medical injections and the provision of unsafe injections are needed.

Below:  Number of persons (N = 242) infected with human immunodeficiency virus, by date of diagnosis — Roka Commune, Cambodia, November 9, 2014–February 28, 2015

More and via:    http://goo.gl/Lk9WJC

By:  Mean Chhi Vun1; Romeo R. Galang2; Masami Fujita3; William Killam4; Runa Gokhale2; John Pitman5; Dejana Selenic5; Sovatha Mam1; Chandara Mom1; Didier Fontenille6; Francois Rouet6; Saphonn Vonthanak7 
1Cambodia National Center for HIV/AIDS, Dermatology and STD; 2Epidemic Intelligence Service, CDC; 3World Health Organization, Cambodia; 4Division of Global HIV/AIDS, CDC, Phnom Penh, Cambodia; 5Division of Global HIV/AIDS, CDC; 6Institut Pasteur du Cambodge, Phnom Penh, Cambodia; 7Cambodia University of Health Sciences.

Factors Associated with the Failure of First & Second-Line Antiretroviral Therapies in Cambodian HIV-1 Infected Children

BACKGROUND:

Little is known about the efficacy of first and and second-line antiretroviral therapies (ART) for HIV-1 infected children in resource limited Southeast Asian settings. Previous studies have shown that orphans are at a higher risk for virological failure (VF) in Cambodia. Consequently most of them required transfer to second-line ART. We assessed the factors associated with VF among HIV-1 infected children who were either under first-line (mostly 3TC + D4T + NVP) or under second-line (mostly ABC + DDI + LPV) therapies at a referral hospital in Cambodia.

METHODS:

A case-control study was conducted from February to July 2013 at the National Pediatric Hospital among HIV-1 infected children (aged 1-15 years) under second-line ART (cases) or first-line (matched controls at a ratio of 1:3) regimens. Children were included if a HIV-1 RNA plasma viral load (VL) result was available for the preceding 12 months. A standardized questionnaire explored family sociodemographics, HIV history, and adherence to ART. Associations between VF (HIV-1 RNA levels ≥1000 copies/ml) and the children's characteristics were assessed using bivariate and multivariate analyses.

RESULTS:

A total of 232 children, 175 (75.4 %) under first-line and 57 (24.6 %) under second-line ART, for a median of 72.0 (IQR: 68.0-76.0) months, were enrolled. Of them, 94 (40.5 %) were double orphans and 51 (22.0 %) single orphans, and 77 (33.2 %) were living in orphanages. A total of 222 children (95.6 %) were deemed adherent to ART. Overall, 18 (7.7 %; 95 % CI 4.6-11.9) showed a VF, 14 (8.6 %; 95 % CI 4.8-14.0) under first-line and 4 (7.0 %; 95 % CI 1.9-17.0) under second-line ART (p = 0.5). Their median CD4 percentage was 8 % (IQR 2.9-12.9) at ART initiation. Children under second-line ART were older; more often double orphans, and had lower CD4 cell counts at the last control. In the multivariate analysis, having the last CD4 percentage below 15 % was the only factor associated with VF for ART regimen separately or when combined (OR 40.4; 95 % CI 11-134).

CONCLUSIONS:

The pattern of risk factors for VF in children is changing in Cambodia. Improved adherence evaluation and intensified monitoring of children with low CD4 counts is needed to decrease the risk of VF.

Below:  Flow chart of first and second-line ART children enrolled in National Pediatric Hospital, Cambodia

Full article at:   http://goo.gl/fiJ5b1

By:  Hubert Barennes, Kang Virak, François Rouet, Yves Buisson, Michel Strobel, and Ung Vibol

Agence Nationale de Recherche sur le VIH et les Hépatites, Preah Monyvong Blvd, Phnom Penh, Cambodia

Institut de la Francophonie pour la Médecine Tropicale, Vientiane, Lao People’s Democratic Republic

ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Univ. Bordeaux, 33000 Bordeaux, France

Epidemiology Unit, Pasteur Institute, Phnom Penh, Cambodia

Virological Unit, Pasteur Institute, Phnom Penh, Cambodia

University of Health Science, Phnom Penh, Cambodia

Hubert Barennes, Phone: + 85512983572, Email: rf.oohay@buhsennerab.

BMC Res Notes. 2016 Feb 5;9(1):69.

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Culturally Embedded Risk Factors for Cambodian Husband-Wife HIV Transmission: From Women's Point of View

PURPOSE:

The purpose of this study was to use interview data to examine the validity of a recently published theoretical model of HIV transmission between husband and virginal wives in rural Cambodia.

DESIGN:

This study used a qualitative description method with a sample of women diagnosed with HIV/AIDS in Phnom Penh, Cambodia.

METHODS:

Data were collected through in-depth interviews conducted with 15 women who self-identified as having contracted HIV from their HIV-positive husbands. Interviews were conducted in Khmer, translated and back-translated for accuracy, and then coded using deductive content analysis. Trustworthiness of study results was protected through peer debriefing, coding to consensus, and maintaining an audit trail.

FINDINGS:

Each conceptual domain of the prior published theoretical model of HIV transmission was validated and further elaborated by current study data: wives' acceptance of their husbands' involvement with commercial sex workers, the common practice of unprotected sex between HIV-infected spouses and uninfected wives, and wives' beliefs about the value of the ideal Khmer woman. In addition, the current study findings identified a new domain that substantially distinguished between the beliefs and attitudes held about marriage and sex by wives and spouses.

CONCLUSIONS:

Women were not passive recipients of HIV transmission; they reciprocated with behaviors that were consistent with being a good Khmer woman in rural Cambodia, all of which increased their vulnerability to HIV transmission from their HIV-infected spouses. Future interventions or programs should consider all these factors and not overly rely on simplistic educational messages about wearing barriers for HIV transmission during sex.

CLINICAL RELEVANCE:

The refined theoretical model of HIV transmission from this qualitative research can be used to formulate culturally sensitive and embedded programs for curbing intramarital HIV transmission in Cambodia among the rural poor.

Purchase full article at:   http://goo.gl/pB3GkA

By:  Yang Y1, Lewis FM2, Wojnar D3.

• 1Assistant Professor, School of Nursing, Research Institute of Nursing Science, Chonbuk National University, Jeonju, Republic of Korea.
• 2School of Nursing, University of Washington Medical Center Endowed Professor in Nursing, Family and Child Nursing, Seattle, WA, USA.
• 3Associate Professor, College of Nursing, Seattle University, Seattle, WA, USA. 
• J Nurs Scholarsh. 2016 Feb 2. doi: 10.1111/jnu.12193.

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